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A comparison in methods of prevention of local alveolar osteitis
A COMPARISON
IN METHODS ALVEOLAR
OF PREVENTION OSTEITIS
OF LOCAT,
T HAS long been my opinion that, aside from lowered tissue resistance produced locally by trauma in the extraction of teeth, the ingress of mouth fluids into the fresh wound of a tooth socket is principally responsible for the condition known commonly as dry socket (local alveolar osteitis). I do not mean that the saliva per se is the etiological factor in producing alveolar osteitis, but the fact that the saliva, even in the most healthy and hygienic mouths, is infested with a variety of pathogenic organisms cannot be overlooked. These organisms, particularly the low-grade pyogenic variety, I believe to he the actual etiological factor in producing dry socket. In expressing this opinion, I am not forgetting that trauma is a definite factor in certain cases, because it is a proven fact that lrauma produces lowered local tissue resistance, and, if it is severe enough, actual death of the tissues will ensue. Also, I am mindful of the presence of the preoperative infection, which is, after all, the reason for extraction in the majority of cases. It must l)e remembered, however, that this infection, existing before extraction is performed, is usually of a chronic type and the defense mechanism of the body has become activated by the very onset of the infection in an effort to cope with the situation. Usually the inflammatory reaction produced is of a mild character, depending, of course, on the degree of severity of the initial infection. Over a period of time, this mild chronic inflammat,ory process succeeds in building a limiting or protecting zone or “walling off” of the infection, which protects the bone from furt,her invasion. This limiting zone (healthy granulation) also more or less protects the nerve ending in the area, which, to me, explains why, in so many cases of definite long-standing infections, we do not get painful dry sockets, despite the fact that the central portion of the infected area consists of unhealthy granulations (grannloma). With this condition present, the devitalized tooth in position acts as a constant irritant, and t,he process of inflammation is a continuous one. Such factors as lowered bodily resistance or excessive pressure on the tooth in biting. or both, may cause the chronic condition to become acute at any time. Let me say here that extraction in acute conditions is definitely cont,raindicated, unless there is actual clinical indication that pus is present around the roots of the tooth and that drainage might be established by extracting the t.ooth. In the majority of such cases, I find that bleeding is slight, and, with open and free drainage, healing is ra.pid and without complications. In cases where bleeding is as w-e normally expect, the formation and mainThe maintenance tenance of a healthy blood clot are essential to proper healing. of a healthy blood clot is my aim in using silver foil. By covering the socket with silver foil immediately following extraction, we can, to a great degree,
I
95
L. T. Russell, Jr.
96
seal the socket against the entrance of bacteria-infected saliva, which, I believe, will prevent subsequent disintegration of the blood clot and infection of the alveolar socket. In the following clinical experiment and observations, I have omitted ext,ractions involving radical surgery, or cases which would naturally necessitat,e more than the ordinary amount of trauma, such as impactions or extractions which are classed as difficult. In one hundred cases of simple extraction I have employed silver foil as a means to prevent the saliva, as much as possible, from entering fresh socket wounds. Also, in one hundred cases of simple extractions I have used one of, or a combination of sterile gauze sponges over the socket and pressure, for ten minutes. In one hundred other cases of simple extraction I have used only the sterile gauze sponges (as control).
Fig.
1.
In carrying out the experiment, 1 made no choice in patients or extractions; starting with the first as outlined above, every third case became a control. Observations
are as follows :
1. Control (gauze sponge only) 2. Sulfa drugs 3. Silver foil
14 cases of osteitis out of 100 (5 severe) 9 cases of osteitis out of 100 3 cases of osteitis out of 100 (all mild)
Technique.-Before extraction, cut a small strip of silver foil (adhesive) to the approximate width of the space to be left when the tooth is removed. This width should be the mesiodistal measurement of the crown of the tooth The length of the strip should be determined by the dis(approximately). tance from the buccal or labial sulcus molded across the ridge and ending just short of the floor of the mouth. Immediately following extraction, mop blood and saliva from the area with sterile sponge; in so doing you will dry the mucosa sufficiently to permit
the foil to adhere properly.
Methods
of Prevention
of Local Alveolar
Osteitis
9Y
The foil, having been properly cut to size, is placed around the bulb of the index finger (adhesive surface outward) and carried to the socket. With the other hand use either finger or instrument to mold the foil to place (Fig. 1). Then, with the index fingers of both hands, hold the foil in place for a few seconds. Rinse the mouth and dismiss the patient, after cautioning him to refrain from eating or otherwise displacing the foil for two hours. After six hours, a warm saline mouthwash may be used at two-hour intervals. 418 PROFESSIONALBUILDINU
IN METHODS ALVEOLAR
OF PREVENTION OSTEITIS
OF LOCAT,
T HAS long been my opinion that, aside from lowered tissue resistance produced locally by trauma in the extraction of teeth, the ingress of mouth fluids into the fresh wound of a tooth socket is principally responsible for the condition known commonly as dry socket (local alveolar osteitis). I do not mean that the saliva per se is the etiological factor in producing alveolar osteitis, but the fact that the saliva, even in the most healthy and hygienic mouths, is infested with a variety of pathogenic organisms cannot be overlooked. These organisms, particularly the low-grade pyogenic variety, I believe to he the actual etiological factor in producing dry socket. In expressing this opinion, I am not forgetting that trauma is a definite factor in certain cases, because it is a proven fact that lrauma produces lowered local tissue resistance, and, if it is severe enough, actual death of the tissues will ensue. Also, I am mindful of the presence of the preoperative infection, which is, after all, the reason for extraction in the majority of cases. It must l)e remembered, however, that this infection, existing before extraction is performed, is usually of a chronic type and the defense mechanism of the body has become activated by the very onset of the infection in an effort to cope with the situation. Usually the inflammatory reaction produced is of a mild character, depending, of course, on the degree of severity of the initial infection. Over a period of time, this mild chronic inflammat,ory process succeeds in building a limiting or protecting zone or “walling off” of the infection, which protects the bone from furt,her invasion. This limiting zone (healthy granulation) also more or less protects the nerve ending in the area, which, to me, explains why, in so many cases of definite long-standing infections, we do not get painful dry sockets, despite the fact that the central portion of the infected area consists of unhealthy granulations (grannloma). With this condition present, the devitalized tooth in position acts as a constant irritant, and t,he process of inflammation is a continuous one. Such factors as lowered bodily resistance or excessive pressure on the tooth in biting. or both, may cause the chronic condition to become acute at any time. Let me say here that extraction in acute conditions is definitely cont,raindicated, unless there is actual clinical indication that pus is present around the roots of the tooth and that drainage might be established by extracting the t.ooth. In the majority of such cases, I find that bleeding is slight, and, with open and free drainage, healing is ra.pid and without complications. In cases where bleeding is as w-e normally expect, the formation and mainThe maintenance tenance of a healthy blood clot are essential to proper healing. of a healthy blood clot is my aim in using silver foil. By covering the socket with silver foil immediately following extraction, we can, to a great degree,
I
95
L. T. Russell, Jr.
96
seal the socket against the entrance of bacteria-infected saliva, which, I believe, will prevent subsequent disintegration of the blood clot and infection of the alveolar socket. In the following clinical experiment and observations, I have omitted ext,ractions involving radical surgery, or cases which would naturally necessitat,e more than the ordinary amount of trauma, such as impactions or extractions which are classed as difficult. In one hundred cases of simple extraction I have employed silver foil as a means to prevent the saliva, as much as possible, from entering fresh socket wounds. Also, in one hundred cases of simple extractions I have used one of, or a combination of sterile gauze sponges over the socket and pressure, for ten minutes. In one hundred other cases of simple extraction I have used only the sterile gauze sponges (as control).
Fig.
1.
In carrying out the experiment, 1 made no choice in patients or extractions; starting with the first as outlined above, every third case became a control. Observations
are as follows :
1. Control (gauze sponge only) 2. Sulfa drugs 3. Silver foil
14 cases of osteitis out of 100 (5 severe) 9 cases of osteitis out of 100 3 cases of osteitis out of 100 (all mild)
Technique.-Before extraction, cut a small strip of silver foil (adhesive) to the approximate width of the space to be left when the tooth is removed. This width should be the mesiodistal measurement of the crown of the tooth The length of the strip should be determined by the dis(approximately). tance from the buccal or labial sulcus molded across the ridge and ending just short of the floor of the mouth. Immediately following extraction, mop blood and saliva from the area with sterile sponge; in so doing you will dry the mucosa sufficiently to permit
the foil to adhere properly.
Methods
of Prevention
of Local Alveolar
Osteitis
9Y
The foil, having been properly cut to size, is placed around the bulb of the index finger (adhesive surface outward) and carried to the socket. With the other hand use either finger or instrument to mold the foil to place (Fig. 1). Then, with the index fingers of both hands, hold the foil in place for a few seconds. Rinse the mouth and dismiss the patient, after cautioning him to refrain from eating or otherwise displacing the foil for two hours. After six hours, a warm saline mouthwash may be used at two-hour intervals. 418 PROFESSIONALBUILDINU